Cardiogenic Shock - June_2017

Frederik Meijer

Heart & Vascular Institute

Frederik Meijer Heart & Vascular Institute

Cardiogenic Shock

for the Intensivist

Michael Dickinson, MD, FACC, FHFSA

Section Chief, Advanced Heart Failure

Medical Director for Heart Failure and Heart Transplant

Richard DeVos Heart & Lung Transplant Program


Spectrum Health


Disclosures

None relevant to this presentation.

3


Presented to rural ER with chest

pain

Suffered VF arrest in the ER x 2

Resuscitated back to a pulse

after 15 minutes of CPR.

Intubated, on ventilator and

neurologic status unclear.

Cooling protocol initiated and

transferred to the Meijer Heart

Center for cardiac cath.

51 yr old man with chest pain

LAD was then stented.


Cardiac Catheterization – acute stent thrombosis

• Recurrent VF

arrests and

hypoperfusion

despite very high

dose pressor and

inotrope doses.

• Maximal medical

support but the

odds of survival

were now very

low.


Shock Team activation


Clinical Course

Cooling protocol performed.

Clinical condition worsened.

Artificial lung added onto circuit

(ECMO)


Clinical Course

Cooling protocol performed.

Clinical condition worsened.

Artificial lung added onto circuit.

After 4 days was weaned from

artificial lung and then off

tandem heart.

■ Cardiac function normalized.

■ Neurologic function normalized.

■ He is fully functional now.

■ He works full time and supports his

family.


What is “a changin”?

Acute mechanical circulatory support (ECMO, Impella, etc…)

Failure to rescue

Recognize and treat the variable hemodynamics

9


38 year old man admitted for heart failure. Known NIDCM

5 pm: Routine

admission orders. Lasix

40 mg IV.

2 am: BP low. RN calls

PA. IVF bolus given.

2:20 am: Dyspneic,

hypoxemic, hypotension (Dopamine)

3:15 am: Cardiac

arrest and died.

10


38 year old man admitted for heart failure. Known NIDCM

5 pm: Routine

admission orders. Lasix

40 mg IV.

2 am: BP low. RN calls

PA. IVF bolus given.

2:20 am: Dyspneic,

hypoxemic, hypotension (Dopamine)

3:15 am: Cardiac

arrest and died.

11


What causes failure to rescue?

Not detected

Not recognized

Not acted upon

Not escalated

12

When patient instability / decline / failure is:


Hospital Mortality Heart Failure Admissions @ SH

2.80%4.40% 5.20%

8.20%

15.60%17.40%

26.70%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Nesiritide Nes + Ntg Nitroglycerin Dobutamine Nes + Mil Milrinone Nes + Dob


What does this data tell us?

• If a clinician feels the

need to use inotropes

that patient has just

become high risk

(>8% in hospital

mortality).

• Once you use more

than one vasoactive

your patient has

become very high risk.

2.80%4.40% 5.20%

8.20%

15.60%17.40%

26.70%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Nesiritide Nes + Ntg Nitroglycerin Dobutamine Nes + Mil Milrinone Nes + Dob


What about with STEMI? Predictors of Survival

Predictor Yes (3yr/6 yr) No (3 yr/6 yr) p

Systemic hypoperfusion not rapidly reversed with IABP

20.6/16.5 43.3/32.9 <0.0001

Baseline Cr >=1.9 13.8/13.8 37.9/29.5 0.0002

LVEF < 25% 29.9/19.2 50.8/40.9 0.002

Prior MI 22.9/15.3 40.2/31.0 0.005

PCWP >=25 28.3/22.0 43.8/33.4 0.01

No lytic therapy at index MI 28.8/18.6 39.3/31.4 0.016

Shock on admission 24.8/12.4 36.7/28.5 0.016

Hx hypertension 30.5/18.2 39.6/34.0 0.027

Multivessel disease 37.6/28.2 64.5/49.2 0.044

Age >=75 20.6/20.6 38.2/27.6 0.06315


What about with STEMI? Predictors of Survival

Predictor Yes (3yr/6 yr) No (3 yr/6 yr) p

Systemic hypoperfusion not rapidly reversed with IABP

20.6/16.5 43.3/32.9 <0.0001

Baseline Cr >=1.9 13.8/13.8 37.9/29.5 0.0002

LVEF < 25% 29.9/19.2 50.8/40.9 0.002

Prior MI 22.9/15.3 40.2/31.0 0.005

PCWP >=25 28.3/22.0 43.8/33.4 0.01

No lytic therapy at index MI 28.8/18.6 39.3/31.4 0.016

Shock on admission 24.8/12.4 36.7/28.5 0.016

Hx hypertension 30.5/18.2 39.6/34.0 0.027

Multivessel disease 37.6/28.2 64.5/49.2 0.044

Age >=75 20.6/20.6 38.2/27.6 0.06316


So we can say:

NIDCM: Patients who need inotropes (esp > 1 moderate dose)

are high risk. Even if they respond and improve, they are at

risk for the future.

STEMI: Initiate intentional meaningful surveillance:

• If shock doesn’t rapidly reverse with IABP,

• Baseline Cr >=1.9,

• Very low EF (<25%),

• Persistent PA wedge >25 (high LVEDP at cath)

• Advanced age, prior MI, etc…

17


What is optimal care?

Detect

• Vitals

• Feel (warm/cold)

• Look (JV pressure)

• Watch urine output, mentation, etc..

Recognize

• Inotropes = risk (two = high risk)

• Unstable after PCI = risk

• Tachycardia, poor urine output

Act

• Intensive surveillance

• Hemodynamic assessment and treatment.

Escalate

• Call for help.

• Shock call -mechanical circulatory support

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Most of the time a code is called, we should view it as a

failure. How did we not act before it got to this point?


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Hemodynamic: Not algorithmic

20

Filling: Enough? Too much?

Pump: Contractile strength / cardiac output?

Vascular tone: Vasoconstricted or vasodilated

(vasoplegia)


Vasoplegia

• Low SVR state

• Not well understood but

likely mediated by

inflammatory mediators

• Common in cardiorenal

syndrome

• Common after

resuscitation

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How do you handle vasoplegia?

22

1. Stop vasodilators.

2. Give vasoconstrictors.

3. Correct acidosis.

4. Give them as much

cardiac output as you

can. (Concept of “not

enough” CO)

5. Methylene blue


But which drug?

Dopamine:Mostly a vasoconstrictor.

Tachycardia

Norepinephrine: Mostly a vasoconstrictor.

Phenylephrine: Vasoconstrictor.

Milrinone:Inodilator (inotrope plus

vasodilator)

Dobutamine: Inodilator (mostly inotrope)

Epinephrine:Inoconstrictor (inotrope plus

vasoconstrictor)

Nitroprusside: Arterial Vasodilator

Nitroglycerin: Venodilator23


How about in cardiac surgery?


Inotrope level predicted mortality

0%10%20%30%40%50%60%70%80%

Mortality

Mortality


Why did they look at this data?

“Early in our experience, we had no

formal insertion criteria. Patients

were placed on VAD support

after "maximal inotropic support”

and an IABP failed to improve

cardiac hemodynamics,

particularly cardiac output. As a

consequence of this, VADs were

being placed at the surgeon's

discretion and results were poor;

the devices were being placed

late and the incidence of MOSF

was high.” ZERO % survival…

VAD Insertion

Formula:If 2 or more high

dose inotropes and

ongoing

cardiogenic shock,

then place the

VAD.


Did it make a difference?

Before After

Placed within 3 hours of

first attempt to wean from

CPB

22% 85%

Placed late (>3 hours) 78% 15%

MOSF 78% 15%

Able to be weaned 22% 80%

Survival to discharge 0% 40%


Did it make a difference?

Before After

Placed within 3 hours of

first attempt to wean from

CPB

22% 85%

Placed late (>3 hours) 78% 15%

MOSF 78% 15%

Able to be weaned 22% 80%

Survival to discharge 0% 40%


What are the lessons?

• The degree of inotropic support needed predicts survival.

• The mortality curve takes an exponential increase starting

at one high dose inotrope. This is when to “blink”.

• Physicians when left to their own clinical judgment try too

hard to get by without mechanical circulatory support.

• In this setting the outcomes with VAD were terrible.

• Having a rigor which forces you to take the leap to the next

step improves the outcomes with the use of mechanical

circulatory support.

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What does this all mean?

Recognize high risk patients

• Signs/sxsof shock

•

•

• Inotrope need, etc.

• Low BP

• Cool, clammy, low u/o




• Signs/sxs of shock

Engage Surveillance

• Active

• Intentional

• Responsive

•


• Low BP


• Urine output

• Swan/A-line

• Serial ABG

(q2 or q4 hr)




• Signs/sxs of shock

Engage Surveillance

• Active

• Intentional

• Responsive

Engage the shock team

• Shock team criteria


• Low BP


• Urine output

• Swan/A-line

• Serial ABG

(q2 or q4 hr)

Shock Team Process

Shock Team

AHF Cards

CT Surgery

CTCC

CV anesth

ECMO team

ChrgRNs

Imaging

IntervCards

33

Rapid, complex

decisionsRapid,

deployment


Urgent MCS is HARD to do.. (fast decisions & deployment)

• Which patients?• To act or NOT to act?

• Which modality?

• How to get it all in

place quickly?• Where? OR, ICU, Cath lab,

ER?

• Who? Surgeon, Cardiologist

(Who is qualified and

available?)

?34


Extracorporeal CPR (ECMO during CPR)

35

In hospital cardiac arrests

• 115 conventional ACLS / CPR (CCPR)

• 59 extracorporeal CPR (ECMO + CPR and ACLS)

Lancet 2008; 372: 554–61


ECPR provided significant benefit

93.2%

76.3%

44.1%

33.9%

38.1%

31.0%

21.2%

15.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 3 14 30

ECPR Survival

CCPR Survival

36

Time (days)


This was not ECPR for EVERY arrest

Notes:

Out of 975 cardiac

arrests, 174 came

into the research

protocol, (59

ECPR)

(Patients that did not

rapidly respond to

usual ACLS.)

37

801

11559

Management

Not in trial

CCPR

ECPR


Survival based on CPR duration

38


Survival based on CPR duration

Notes:

• If initial ACLS does

not revive them

ECPR ALWAYS

had better survival.

• Survival rates

varied between 17

and 42%. (STILL

between 60 and

80% mortality).

• 18% survived with

extreme durations

of CPR39


Survived after 3 hours of CPR...

40


What do this and other reports teach us?

• If you can urgently deploy

mechanical circulatory support

you can save ACLS refractory

patients.

• Still VERY HIGH mortality

(survival around 25-30%)

• Probably an OK thing to do for

the right candidates.

• Can we better select the “best

use” of this resource?41

Is this patient capable of

surviving a massive insult?


Intra-aortic balloon pump (IABP)

Use is becoming much

less.

42


ISAR-SHOCK

13 IABP vs. 12 Impella

• Better immediate CI

improvement

• More anemia

• 1 incident of limb

ischemia

Too small. Unanswered

questions.43


IABP-SHOCK II

300 IABP vs. 298 control

• No difference in mortality

• Trend toward benefit if

age < 50 or first MI

Questions:

• RCA (RV infarcts?)

• Cross over? Selection

bias?

• Rapid PCI trumps

everything else

44


Impella

Versions:

• 2.5 for protected PCI

• CP (3.5) for protected

PCI and acute

cardiogenic shock

• 5.0 = surgically placed

• RP = right sided

45


Impella lessons learned

1. Hard to use in very dilated hearts.

2. You can’t ask it to do more than it can do.

• If you need 5 liters then use something that delivers 5 liters.

• If you just stomp on the gas you will get hemolysis.

3. A good tool for the acute ischemic heart.

46


47


48


Early Impella had higher survival

49


Centrimag

Very nice pump with

favorable hemolysis

profile.

Surgically placed.

Common to use atrial

inflow. (Beware

microembolic events

from native LV)

Durable device.50


ECMO = ExtraCorporeal Membrane Oxygenation

• Remove blood.• Oxygenate the blood

• Remove CO2 from the blood

• Warm the blood

• Return the blood and

pump it at desired flow

(2-6 liters/minute)

• Components:• Pump = Replace heart fxn

• Oxygenator = Replace lung fxn51


ECMO MODE: Proportion of VA to VV

Definition: Percent of patients > 18 years old with VA vs VV access.

“VA” = VA, VA+V and VA-VV

“VV” = VV, VVDL and VVDL+V

Source: ELSO Data

VA84%

VV16%

Adult ECMO Patients Broken Down by Mode

2015

(82/98)

(16/98)


ECMO Survival: Patients Discharged Alive

53

Percent of patients > 18 years of age that were discharged alive vs. those who

died during this hospitalization (All Causes) Source: ELSO Data

Survived63%

Died37%

Adult ECMO Patients2015

(36/98)

(62/98)


ECMO Survival: by VA or VV Mode

54

Definition: Percent of patients > 18 years old with VA vs VV access.

“VA” = VA, VA+V and VA-VV

“VV” = VV, VVDL and VVDL+VELSO survival: Cardiac 39% Respiratory 55%

Source: ELSO Data

Survived63%

Died37%

Adult VA Patients 2015

(31/83)

(52/83) Survived67%

Died33%

Adult VV Patients2015

(5/15)

(10/15)


ECMO Survival: ECPR

55

Survival of Adult ECMO Patients with ECPR

2015

Source: ELSO Data

(2/6)

(4/6)

(2/6)

(4/6)

Survived33%

Died67%

(4/6)

(2/6)


Acute MCS: Immediately ask, “What next?”

Early crossover

was mean

mean 2.5 +-

0.8 days

Late crossover

was mean 6.7

+- 3.2 days

56Artif Organs. 2017 Mar;41(3):224-232. doi: 10.1111/aor.12758. Epub 2016 Sep 23.


Summary

• Detect / Recognize / Act / Escalate• “You are so important that we are going to do more

than might be necessary.”

Failure to Rescue

• Not a cookbook.

• Wet or dry? Cold or warm? Vasoconstricted or vasodilated?

Hemodynamic Treatment

• Acute MCS can and is saving people who normally would have died.

• “The times – they are a changin!”Shock Team

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QUESTIONS / COMMENTS?Thanks for your attention!

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Cardiogenic Shock - June_2017